Live Case Session Showcasing Safety Skirts Disaster at EuroPCR

Shelley Wood

March 03, 2014

PARIS, FRANCE — A live-case presentation at last year's EuroPCR meeting aimed at how to avoid fatal complications during interventional procedures narrowly skirted disaster, a Swiss magazine has revealed. In the video of the live case presented last May, led by University Hospital Zurich chief cardiologist Dr Thomas Lüscher, the 72-year-old female patient undergoing elective PCI of her LAD goes into ventricular fibrillation (VF) that appears to go unremarked by the cardiologists until members of the panel and audience point it out. Seconds then tick by while the operators on camera tried to locate a defibrillator.

The video is not available on the EuroPCR website but has been published on the website of the magazine, Die WeltWoche, which reports that the video "disappeared" from the EuroPCR platform.

The case and the interest it is garnering so many months after the fact will no doubt rekindle discussions about the educational role—and potential risks—of live cases at cardiology meetings.

Anticipating and Preventing Problems

Ironically, the name of the 2013 session was "Interventional procedures complicated with fatal outcome." The live case, according to introductory comments by the moderator in Paris, Dr Marie-Claude Morice (Institut Hospitalier Jacques Cartier, Paris, France), was intended to demonstrate that "safety is crucial." At each stage, she explained, the live case—an elective PCI in a patient who'd undergone two previous interventions—would show the audience "how to anticipate what can occur and how to prevent it." Following the live broadcast, six different speakers presented past cases that had gone horribly wrong.

The showcase live procedure, however, didn't quite go according to plan.

At the 32-minute mark in the video—while Lüscher and colleagues, in Zurich, are engaged in a discussion with the panelists in Paris regarding the best approach to averting contrast nephropathy—the patient goes into VF. In the video, Lüscher and his colleagues appear to be focused on the catheter and Lüscher is heard saying, "we have a problem," then, "we had a problem with the patient," and "no, no, it's okay."

A rumble of conversation can be heard in the background, and moderator Maurice says calmly: "You need a defibrillator," at which point Lüscher says, "Defibrillation, defibrillation, where is the defibrillator? We did a mistake while talking . . ." At this stage, the video camera moves behind a monitor and viewers can no longer see what's happening with the patient.

Morice asks the technicians to show the ECG instead, but her request goes unheeded. The live feed is stopped shortly thereafter so that the Zurich team can focus on their patient, at which point Maurice exhorts the audience to settle down, saying, "There is so much noise in the room that we can't hear each other!"

She then reminds attendees: "VF during a procedure; we [have] all had that sometime. You give a shock and that's it. This is not a big deal. This is part of the life of interventional cardiolog[ists]."

Audience Disapproval

Later in the session, the live feed returns to the Swiss team and their stabilized patient, and Lüscher agrees with comments made by one of the Paris panelists and an audience member, that the VF may have been caused when the catheter was advanced too far into the proximal LAD. "Mea culpa," Lüscher says.

He and the panel continue to discuss best practices, stent sizing, and imaging findings, including optical coherence tomography (OCT) as the case progresses. By the 46-minute mark, this protracted to-and-fro prompts an audience member to head to the microphone, where he takes a few moments to try to get the attention of the live team in Zurich.

"I'm coming from a small country, and I must say, in my cath lab, this is a seven-minute case with a femoral puncture, and I really don't see what [the] case is here," he says. In imperfect English, he ventures his opinion that the case could have been done with less contrast (the patient has chronic renal failure), direct stenting with a bare-metal stent, and no advanced imaging tests: "End of the story! This was a six-contrast shut case: no much technology, no much OCT, not playing with all this discussion!"

This statement is met with loud applause from the audience.

Maurice, at this point, tries to settle the crowd, saying, "Let's say there is never one truth in interventional cardiology," and turns discussion back to the case.

Live Cases and Outcomes

Lüscher confirmed in an email to heartwire that the patient treated in the live case is doing well: the angiographic results of the stent placement were perfect, LV function and perfusion as assessed by PET are normal, and the patient now exercises normally.

Interventional cardiology live cases are very popular at meetings like EuroPCR and TCT but have faced their share of defenders and detractors over the years. In 2010, several cardiology societies issued guidelines with recommendations as to how and when live procedures should be included at medical meetings.

Other medical specialties have taken the decision to discontinue live case presentations at their meetings, out of concerns that potential risks to patients outstrip educational benefits.

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